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Electrician Apprentice Dies Following a 55-foot Fall From a Roof

Wisconsin FACE 93WI254

SUMMARY:

A 21-year-old male electrician apprentice (the victim) died of injuries received after falling 55 feet
from a roof. The victim was working with a journeyman electrician to install conduit and wiring for a surveillance camera
on the flat roof of a hospital. An eighteen-inch high ledge surrounds the roof edge, and a wire rope guard railing was
located 20 feet from each roof edge. The victim was standing outside the guard railing and was using a reel pulling tape
to pull de-energized electrical wire through a conduit. There were no witnesses to the incident, and it appears he
inadvertently stepped to the edge of the roof and fell 55 feet to the ground. The electrician was replacing the cover on
a pull box about 40 feet away from where the victim had been standing and looked for him in that location. He noticed that
the electrical wires were over the edge of the building, went to the edge to look over, and saw the victim lying near the
base of the building. The victim was moved to the hospital emergency room, where he was pronounced dead of massive head
trauma. The Wisconsin FACE investigator concluded that, to prevent similar occurrences, employers should:

evaluate their current safety program and incorporate specific training procedures emphasizing the importance of
recognizing and avoiding hazards in the workplace. These procedures should include, but not be limited to, conducting
hazard evaluations before initiating work at a job site and implementing appropriate controls

ensure that fall protection equipment is provided and used by workers where the potential for a fall from an
elevation exists

conduct scheduled and unscheduled site visits to evaluate field compliance with company safety rules and procedures

INTRODUCTION:

On November 16, 1993, a 21-year-old male electrician apprentice (the victim) died after falling 55
feet from a roof. The Wisconsin FACE investigator was notified by the Wisconsin Department of Industry, Labor and Human
Relations, Workers Compensation Division, on November 24, 1993. On December 15, 1993, the WI FACE field investigator
initiated an investigation of the incident with an interview of the owner of the company. The investigator obtained
copies of the coroner's report, death certificate, police report and photographs, OSHA citations, and viewed a videotape
of the incident site that was recorded several hours after the incident. The investigator conducted a visit to the site
of the incident on April 18, 1994, and interviewed the company safety director and a security officer of the building
where the incident occurred who was on duty at the time of the incident.

The employer in this incident was an electrical contractor that had been in operation for 75 years and
employed about 325 workers, of which approximately 57 were electrician apprentices. The employer had a safety director
who implemented a formal safety program which included providing training films at new employee orientation and during
continued employment, and making monthly site visits with the foremen of major jobsites to discuss safety aspects of these
jobs and to conduct periodic safety inspections. In addition, the foremen were directed to conduct weekly toolbox safety
talks at each jobsite. There were no written job-specific safety procedures, or records of safety training and discussions.

The safety director met new employees to provide a general description of company safety policies, before
they were assigned to jobsites. Apprentice electricians were selected from a union pool after completion of a formal training
program, and received on-the-job training, direction and supervision from senior journeyman electricians. The teams of
apprentice and journeyman electricians were assigned to work together until a project was completed, and then might be assigned
separately to different projects. Apprentices usually worked at the company for about six months, and then returned to the
union pool for reassignment as an apprentice. The victim had worked for the company for four months prior to the incident.
This was the first fatality the company had experienced.

INVESTIGATION:

The victim was working with a journeyman electrician (the co-worker) to install conduit and wiring for
a surveillance camera on the flat roof of a five-story hospital. Work on the project had been in progress for 3 days
before the incident, however the day of the incident was the first day that the victim had worked on the roof. The victim
and the co-worker had been working together for approximately one week.

On the day of the incident, the victim and co-worker arrived at the site and started work on the roof
at approximately 7:30 a.m. There were no other workers on the roof on the morning of the incident. The weather conditions
were overcast with no precipitation or wind. The flat roof had a tar and pea gravel surface and was dry at the time of the
incident. An eighteen-inch high, 3½ inch-wide ledge surrounds the roof edge, and a wire rope guard railing was
located 20 feet from each perimeter edge. The two wire-rope guardrails are approximately 42" and 21" high, and
are strung through concrete support poles. Personal protective equipment, including safety harnesses and lifelines, were
available for company employees in a construction trailer located on the hospital grounds, but were not being used by the
victim or his co-worker.

The workers had spent the morning installing conduit and electrical wires to be connected to a camera
at the northeast corner of the roof. The victim was using a "fish tape reel", a hand-held device used by
electricians to pull electrical wires through conduit. The line of the reel was attached to three de-energized electrical
wires that were pulled through the conduit as the reel was turned. The conduit was attached to the bases of the concrete
guardrail support poles and then bent around a corner outside of the guardrail and extended to the ledge wall on the east
side of the building, about 20 feet from the northeast corner where the camera was located. The electrical wires emerged
from the conduit at the point where the conduit met the ledge wall. At approximately 10:45 a.m., the co-worker saw the
victim outside of the guardrail area, holding the reel and facing south. The co-worker was kneeling about 40 feet away,
and looked away for about 30 seconds to replace the cover on the conduit junction box. When the co-worker looked back,
the victim was gone and the wires were over the north edge of the roof. The co-worker went to the edge to look over, and
saw the victim lying face down near the base of the building with two people standing nearby. The co-worker went inside
to call for help, then went to the victim's location. The victim was moved to the hospital emergency room, where he was
pronounced dead of massive head trauma.

CAUSE OF DEATH:

The medical examiner reported the cause of death as head trauma.

RECOMMENDATIONS/DISCUSSION

Recommendation #1: Employers should evaluate their current safety program and incorporate specific
training procedures emphasizing the importance of recognizing and avoiding hazards in the workplace. These procedures should
include, but not be limited to, conducting hazard evaluations before initiating work at a job site, and implementing
appropriate controls.

Discussion: Safety programs should be evaluated and training
procedures incorporated which emphasize the importance of recognizing and avoiding
hazards in the workplace, following established safe work procedures, and wearing
appropriate personal protective equipment. In this incident, the hazard of working
near the unguarded roof edge without fall protection equipment was apparently
not recognized by the workers. Since the incident, the company has expanded
the written safety program to include specific fall protection information and
maintaining records of all training activities.

Recommendation #2: Employers should ensure that fall protection equipment is provided and used by
workers where the potential for a fall from an elevation exists.

Discussion: Fall protection equipment should be immediately
available for workers when there is a possibility that their work tasks will
involve exposure to an unprotected roof edge. In this incident, the work tasks
involved installing conduit along the 18-inch high roof ledge. Fall protection
equipment was available in a construction trailer located near the incident
site, but was not being used by the workers on the roof.

Recommendation #3: Employers should conduct scheduled and unscheduled site visits to evaluate
field compliance with company safety rules and procedures.

Discussion: Employers should conduct scheduled and unscheduled safety inspections of work sites to
help ensure that employees are performing their assigned tasks according to established company safety rules and procedures.
The company in this incident had one safety officer who directed the safety program for 325 employees at multiple worksites,
and visited the major sites once or twice a month. He was not always able to visit smaller contract sites (as in this
incident). To be effective, a safety program must be enforced at each worksite by the supervisor and any unsafe conditions
should be corrected immediately. Such inspections also demonstrate that the employer is committed to the company safety
program and to the prevention of occupational injury.

FATAL ASSESSMENT AND CONTROL EVALUATION (FACE) PROGRAM

FACE 93WI25401

Staff members of the FACE Project of the Wisconsin Division of Health, Bureau of Public Health, perform
FACE investigations when there is a work-related fatal fall, electrocution, or enclosed/confined space death reported. The
goal of these investigations is to prevent fatal work injuries in the future by studying: the working environment, the worker,
the task the worker was performing, the tools the worker was using, the energy exchange resulting in fatal injury and the
role of management in controlling how these factors interact.